MD Update Issue 151

ALSO IN THIS ISSUE

PROSTATE CANCER SCREENING BY KPCC GASTROENTEROLOGY AT UOFL HEALTH

UROLOGY AT CHI SAINT JOSEPH HEALTH MT. STERLING

COLON CANCER SCREENING AT NORTON HEALTHCARE

EATING DISORDERS COUNCIL & THE KPMA

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Steve Lin, MD Medical Director Nezar Falluji, MD

Hussam Hamdalla, MD Sharat Koul, DO

Welcome to the Internal Systems Issue of MD-Update

It’s always a pleasure for me to meet and speak with the doctors we interview for stories in MD-Update, hearing their personal stories, their motivations, and what’s new in their specialty. It’s also enjoyable to reconnect with physicians whom we met years ago and who have started on a new path, such as our cover story in this issue, John Mullins, MD, founder of Marshall Lifestyle Medicine. I hope you enjoy reading about Dr. Mullins’ journey from the ER to lifestyle medicine.

Other stories in this issue include Dr. Kristine Krueger from UofL Health sharing her story about her career focused on nutrition and food’s effect on health as a gastroenterologist. Dr. Michael Driscoll, Norton Cancer Institute, describes the “power of screening” for colorectal cancer. Dr. Brent Terrell talks about “coming home” to Mt. Sterling and his decision to bypass a possible career playing professional baseball to pursue medicine.

Prostate Screening for Kentuckiana Men

The American Association for Cancer Research says that prostate cancer is the “most common, non-skin cancer diagnosed in men and the second leading cause of cancer death in men after lung cancer.” Stephen Henry, MD, former Lt. Governor of Kentucky, and a prostate cancer survivor, established the Kentucky Prostate Cancer Coalition, KPCC, which provides free prostate screenings at the KY State Fair. We’ve included Dr. Henry’s telling of his story and his advocacy for prostate cancer screening on page 4. Dr. Henry took his personal healthcare challenge and turned it into his new passion for helping others.

Cybersecurity, Your Medical Practice, and Financial Forecasting

In this issue’s accounting column, Eric Riley and Gui Cozzi from Dean Dorton point out the devastating effects of a cybersecurity hack and ransomware attack on a national healthcare company. It is an alarming situation and one they suggest will continue to occur. Read more on page 8.

Our financial columnist Scott Neal talks about “Risk or Opportunity” in the stock market and treasury bonds. Scott says he “doesn’t have a crystal ball, but he does have a wind sock.” Daily financial news is most likely to be “noise,” says Scott. Look for underlying causal events as well as symptoms, much like in your medical practice. Scott’s full column is on page 9.

Eating Disorders. New Leadership at KPMA.

We welcomed a new contributor this issue, Dr. Zubi Suleman, UofL Health, and the new president of the Kentucky Psychiatric Medical Association, KPMA. Dr. Suleman writes about the misconceptions and stigma surrounding eating disorders, the lack of awareness, and treatment options in Kentucky. Full story on page 20. MD-Update’s Dr. Jan Anderson gives a recap of the KPMA annual conference on pages 23-24.

A Couple of Fun Nights with the American Heart Association

We enjoyed attending the Kentuckiana and Central Kentucky Heart Balls put on by the Kentucky chapters of the American Heart Association. We have some great pictures of the events for you on pages 30-32. It’s always fun to see our doctor friends outside of work.

The MD-Update editorial calendar is on the preceeding page. When you see your specialty, give me a call. I’d like to hear from you. I’m sure you have an interesting story to tell.

Gui Cozzi

Stephen Henry, MD

Scott Neal, CPA, CFP

Jay L. Phillips, Esq

Eric riley

Zubi Suleman, MD

Sarah Charles Wright, Esq.

Prostate Cancer Advocacy: A Journey of Awareness and Change

Early testing leads to early detection

BY STEPHEN HENRY, MD

In 1993, the news of Frank Zappa’s death at 52 due to advanced prostate cancer shocked many, including myself. As a medical professional, I had been taught that prostate cancer was primarily an ailment affecting older men, leading me to initially dismiss the diagnosis as an anomaly. However, my perception of this disease shifted drastically when at the age of 49, I myself was diagnosed with Gleason 7/10 prostate cancer. This diagnosis necessitated a radical medical prostatectomy in 2003. This personal encounter with the disease shattered my preconceived notions and spurred me into action, making me question the existing screening guidelines and advocate for an earlier protocol.

At the time of my diagnosis, I was serving as the lieutenant governor of Kentucky. Feeling a sense of responsibility to raise awareness about prostate cancer, I compared the screening protocols recommended by the American Cancer Society, National Comprehensive Cancer Network (NCCN) and the United States Preventative Services Task Force (USPSTF). While these organizations suggested screening starting at age 50 to 55, I discovered that many urologists were advocating for baseline PSA screenings as early as age 45 and even 40 for individuals at highest risk. This discrepancy and confusion in recommendations prompted me to establish the Kentucky Prostate Cancer Coalition (KPCC) and initiate free prostate exams and screenings at the Kentucky State Fair, aiming to reach a diverse and sizable audience.

Despite our best efforts and the remarkable growth of KPCC into the largest prostate screening program in the United States by 2010, we encountered challenges with the introduction of the Affordable Care Act and the subsequent D grade rating for PSA screening by the United States Prevention Services

Task Force (USPSTF). This rating allowed health plans to deny coverage for prostate cancer preventive services, significantly impeding our advocacy efforts.

However, amidst these challenges, I found an ally in Governor Steve Beshear, who had also been diagnosed with prostate cancer in his late 40s. His experience highlighted the critical role of a PSA blood test in combination with a normal physical exam. His case emphasized the need for proactive screening measures. Despite the hurdles posed by healthcare policies and guidelines, high profile cases like those of Dan Fogelberg, Rudy Giuliani, and billionaire David Koch underscored the urgency of early detection and the potential impact of timely interventions.

In March 2022, a study published in JAMA further substantiated the link between USPSTF recommendations and advanced prostate cancer diagnoses, citing a marked increase in cases following the restrictions of PSA-based screenings. This study reinforced the necessity of reevaluating existing guidelines and policies to ensure optimal outcomes for patients.

Additionally, initiatives by Louisville-based First Urology, reporting a significant rise in advanced prostate cancer diagnoses, contributed to a broader public discourse on the importance of screenings. Notable figures such as Rudy Giuliani and Ben Stiller shared their experiences, advocating for prostate cancer screenings and highlighting the

life-saving potential of early detection. In Giuliani’s ad campaign he stated, “A five-minute test saved my life…it can save yours.”

Ben Stiller’s public revelation about his prostate cancer diagnosis at age 48 resonated widely, emphasizing the critical role of annual baseline PSA blood tests and physical exams such as a digital rectal examination (DRE). Following his surgery, Ben Stiller told Howard Stern in 2014, “…taking the PSA blood test literally saved my life. Had I waited until age 50 as the American Cancer Society recommended, the tumor would have grown for another two years before I would have received treatment.” His journey, along with the experiences of other advocates, played a pivotal role in shaping revised recommenda-

tions by the American Cancer Society, advocating for screenings at age 40 for high-risk individuals and age 45 for African American men with a positive family history.

Despite ongoing opposition from USPSTF, the collective efforts of advocacy groups, healthcare professionals, and public awareness campaigns have made significant strides in combating advanced prostate cancer. Our organization, KPCC, in collaboration with partners such as the Lexington Cancer Foundation and the Kentucky Cancer Program, have played a crucial role in providing free screenings, education, and counseling to the public, ultimately saving lives and empowering individuals to request a PSA blood test and take proactive steps towards

combatting a leading cause of cancer deaths in men.

As a prostate cancer survivor and advocate, I am deeply grateful for the progress made in raising awareness, challenging outdated guidelines, and ensuring that every man has full knowledge and access to timely screenings and comprehensive care. The journey of prostate cancer advocacy continues, driven by a shared commitment to improving outcomes and reducing the impact of this disease on individuals and families.

PHOTO PROViDED BY KPCC

Former lt. Governor Steve Henry and fellow prostate cancer survivor Governor Steve Beshear during an interview at the Kentucky State Fair advocating for men to get screened for prostate cancer.

Devastating Hack Sends Shockwaves through Healthcare

How this ransomware attack may affect you

BY ERIC RILEY, HEALTHCARE CONSULTING DIRECTOR AND GUI COZZI, CYBERSECURITY PRACTICE LEAD

The cybersecurity situation in healthcare looked bad throughout 2023 when one in every three Americans had their health information breached. But now it looks even worse.

A ransomware attack—currently still in progress—on a UnitedHealth Group subsidiary has caused chaos for patients and providers from coast to coast. It will also have implications for everyone, suggesting that the future of healthcare cybersecurity will be even more difficult and destructive than in the past.

What’s Happening?

An announcement on February 21 revealed that Change Healthcare, which acts as a clearinghouse in the healthcare ecosystem and processes 15 billion transactions annually, had its billing and payment portals affected by a cyber-attack.

As a result, the electronic portals that patients, providers, and insurers depend on to quickly process claims were no longer available, sending shock waves through the status quo. Faced with no other option, some offices have returned to paper forms and manual filing methods—but this has done little to alleviate the issues.

Patients are waiting to get necessary prescriptions and delaying important appoint

ments while the mess gets sorted out. Providers are waiting to bill for their services, causing revenue to slow or stop entirely in some cases. Insurers, sitting in-between, must contend with mountains of paperwork while experiencing their own financial strains.

No wonder the American Hospital Association has called this “the most serious incident” ever to strike America’s healthcare system.

UnitedHealth Group has faced its own consequences. Reports suggest the company paid $22 million to the cyber criminals to end the attack, but to what extent they honor that commitment remains to be seen. Regardless, the financial fallout of the attack will be much larger than that figure once all the technical costs, legal fees, regulatory sanctions, revenue losses, and brand damage are added up.

The systems affected by the hack are still down. They will eventually be restored. As a result of this hack, though, the U.S. healthcare system will never be the same.

What’s Next for Healthcare Cybersecurity?

The long-term effects of this attack will take many forms, but two are worth highlighting here.

First, cybercriminals repeat their tactics until they stop working. Since these criminals just secured an eight-figure payout by putting pressure on a healthcare organization, expect to see a wave of copycat attacks, and no one is exempt. More aggressive cyber-attacks in higher volumes will be a source of stress for the entire industry. Far worse, they could put lives at risk.

Second, regulators at the United States Department of Health and Human Services have been called on to provide subsidies and relieve restrictions, and the agency issued an official statement on the attack. It has their attention. In line with other trends, this incident may eventually result in higher cybersecurity standards required by regulators, insurers, vendors, or most likely all three. Cybersecurity was already an urgent issue in healthcare, but the risk is even greater now, and it’s poised to keep rising with no signs of stopping. What steps is your organization taking to prepare?

Contact Dean Dorton for expertise in healthcare, cybersecurity, and the dynamic place where they intersect.

Contact Eric Riley: eriley@ddafhealthcare.com

Contact Gui Cozzi: gcozzi@ddaftech.com

Is It a Risk or an Opportunity? – 2024

It’s no small wonder that we seem to be living in an era dominated by data-driven analytical thinking. Data are ubiquitous. That can be frustrating to an intuitive that sees the world in systems and thinks from the top down. Nevertheless, I encourage you to persevere.

The most frequent questions we get these days are, “Where is the market going?” “Can this market high really continue?” “Shouldn’t we be going to cash since the market is at an all-time high?” (It was at the time of this writing.) I usually respond to such questions with the caveat that we don’t possess a crystal ball, but we do have a windsock. That answer stemmed from years of experience coupled with knowledge of the ups and downs of the business cycle.

More importantly, I want to know what’s behind any of those questions. “How do you feel currently? Are you experiencing elation at your recent return on investment? Do you have FOMO (fear of missing out) because you haven’t been more fully invested in the Big 7

BY SCOTT NEAL, CPA, CFP®

through this most recent rally? Or do you fear that the next crisis is just around the corner?”

I’m sure you pay attention to how the news outlets report on the stock market and economy. “The Dow was up / down by x points.” Or “Inflation rate is up / down by x percent.” Or “Employment rose / declined by x thousand jobs last month.” They are reporting on the near-term gyrations and assume that every listener a) knows what they are talking about, and b) can apply it to their daily lives in some sort of meaningful way. These are the effects of normal volatility, usually measured by standard deviation. I would like to suggest that investors focus on the news that ultimately matters to the markets. Pay attention to the causes, rather than the effects, i.e., the stories that come before or after the announcements of today’s price level of the DOW or S&P.

So, what is that? It isn’t nearly so much the traditional business cycle news as it is reports about the shocks (both good and bad) caused by events external to the market: e.g. geopolitical events, natural disasters, regulatory changes on taxes and entitlements, wars, and the seismic shift from an industrial economy (manufacturing) to a service economy (you and me).

This concept and identification of potential exogenous shocks were recently brought to light by Dr. Woody Brock.1 He made the point that while the business cycle is not dead, it has far less importance than it has had in the past, and the daily reports of market ups and downs are mainly noise. It is exogenous events that hold a bigger risk and potentially greater opportunity as we look into the future.

Undoubtedly, the impending federal debt crisis, i.e., national insolvency, ranks high on the list. In other papers, Dr. Brock has outlined a valid method of preventing such a 1 H. Woody Brock, What “News” Used to Drive the Markets? What News Will Drive Markets in the Future? What Has Changed? Strategic Economic Decisions, Inc., Profile, February 2024.

crisis, but his method would require a change in law that would allow the Fed and Treasury to work together in a novel way. Since neither major party appears to be presently willing to address this, I hold out little hope that it will be done anytime soon. Meanwhile, you and I must remember that it is ultimately the bond market, not the Fed, that controls long-term interest rates, and to a large extent, the economy.

If you are like most balanced investors who believe in asset allocation, you have likely had a portion of your portfolio in long-term bonds for the last couple of years. You would have seen that portion of your portfolio lose money while the stock market has roared. (For example, iShares U.S. Aggregate Bond ETF dropped by 17% in the first 11 months of 2022 and has only recovered 9% since then. The current yield on that ETF is just a bit over 3.3%.) At the same time, short-term rates have been steadily above 5%.

For most investors, it has made more sense to ladder short-term U.S. Treasury Bills than to remain in long-term bonds through this period. Keeping them short i.e., three months, also maintains a healthy dose of liquidity that could come in handy should one of the exogenous events come to pass.

Understanding the dynamics of exogenous and endogenous risks is essential to investors. By identifying and addressing these risks effectively, stakeholders can mitigate the potential for market disruptions and build a more robust financial system capable of withstanding shocks and challenges. If you haven’t been paying attention to your investments, now is the time.

The Corporate Transparency Act

What do healthcare professionals need to know?

On January 1, 2024, the Corporate Transparency Act (CTA) came into effect, impacting a vast array of small businesses across the United States. This legislation places considerable requirements on small businesses, necessitating the reporting of essential information.

The primary objective of the CTA is to align the U.S. with international anti-money-laundering standards by providing law enforcement with the “Beneficial Ownership Information” (BOI) of small businesses operating in the U.S. for the purpose of detecting, preventing, and punishing terrorism, money laundering, and other crimes conducted through small business entities.

Exemptions and Considerations for Medical Practices

Certain entities are exempt from the regulation, including tax-exempt Section 501(c)(3) corporations and limited liability companies physically operating in the U.S. with more than 20 fulltime employees and over $5 million in annual gross receipts. Medical practices should review these exceptions in consultation with legal counsel, as they apply differently depending on various factors.

What Does the CTA Require?

Under the CTA, the “Beneficial Owners” of most small businesses registered with the Secretary of the state in which they were formed are mandated to report information regarding their owners – their “Beneficial Ownership Information” – to the U.S. Treasury Department’s Financial Crimes Enforcement Network (FinCEN). For each Beneficial Owner, an online report must be filed with FinCEN that includes the Owner’s:

• Full legal name

• Date of birth

• Current residential address (except for

BY JAY L. PHILLIPS AND SARAH CHARLES WRIGHT

business entities, which must provide their business address)

• ID number from an acceptable document (e.g., current Passport or driver’s license)

• An image of the identifying document from which the number is derived

While the reported information will not be publicly available, FinCEN may disclose it to U.S. national security and law enforcement agencies; state and local law enforcement agencies with court approval; certain financial institutions with the Beneficial Owner’s consent; and foreign law enforcement agencies that qualify to receive the information.

Who Is a Beneficial Owner?

A Beneficial Owner is any individual or entity that currently, directly or indirectly, exercises substantial control over the Reporting Company or owns or controls at least 25% of the ownership interests of the company.

Who Is a Company Applicant?

A Company Applicant is the individual(s) who directly files Articles of Organization or Articles of Incorporation with the entity’s state. This may include your attorney or your accountant.

Who Is Exempt?

While there are a number of exempt entities present in the regulation, those most relevant to the practice of medicine include the following:

• A tax-exempt Section 501(c) corporation.

• Certain corporations, LLCs, or other similar entities that operate exclusively to provide financial assistance to or hold governance rights over, tax-exempt Section 501(c) corporations, political organizations, charitable trusts, or split-interest trusts exempt from taxation,

• An entity that employs more than 20 employees on a full-time basis in the United States, filed federal income tax returns in the previous year demonstrating more than $5,000,000 in gross receipts or sales, and that maintains an operating presence at a physical office within the United States,

• A subsidiary of an exempt entity.

The Reporting Company and Beneficial Owner information described above is only a brief summary of the criteria for filing a BOI Report. The regulation itself is far more complex. As always, please consult your attorney to determine if your practice entity

is a Reporting Company or qualifies for an exemption. The exempt status of a business entity is subject to change, as can the status of Beneficial Owners of non-exempt entities.

Why You Must Comply

It is illegal for any person to willfully provide, or attempt to provide, false or fraudulent BOI to FinCEN or to willfully fail to report complete or updated BOI to FinCEN. Any person violating the reporting requirements of the Corporate Transparency Act is liable for civil penalties of not more than $500 for each day that the violation continues and criminal penalties of imprisonment of up to two years and fines of up to $10,000.

When You Should Report

Reporting companies created by registering with the office the Secretary of State of any U.S. State or territory, or a Tribal government, before January 1, 2024, have until January

1, 2025, to file an initial BOI report with FinCEN. Any Reporting Company created or registered with a State in 2024 will have ninety (90) calendar days to file its initial BOI report, from the first to occur of the date the company receives actual or public notice (the first date a corporation’s articles are available online via the State’s business record repository) from their Secretary of State that its creation and/or registration is effective. Reporting companies created or registered on or after January 1, 2025, will only have thirty (30) calendar days to file the initial BOI report from the notice dates described above.

Future of the Act

The CTA is currently in force as a matter of federal law and creates significant regulatory compliance obligations for small businesses, including medical practices. Understanding those obligations and compliance deadlines is crucial to avoid monetary and other penalties.

However, on March 1, 2024, a federal court in Alabama ruled the Act unconstitutional and enjoined FinCEN from enforcing it against the current members of the National Small Business Association, which filed the lawsuit. FinCEN has appealed the decision to the U.S. Court of Appeals for the Eleventh Circuit. The outcome of the appeal, and whether the issue of the Act’s Constitutionality will end up before the U.S. Supreme Court may not be known for at least another year. In the meantime, all other small businesses and practices in the U.S. that are Reporting Companies must comply.

Jay L. Phillips is a business and compliance attorney, and Sarah Charles Wright is a corporate and healthcare law attorney with Sturgill, Turner, Barker & Moloney, PLLC. They can be reached at 859.255.8581.

This article is intended to be a summary of state or federal law and does not constitute legal advice.

BY GIL DUNN

Live Long, Live Well

John Mullins, MD, and Marshall Lifestyle Medicine see a new healthcare paradigm

LEXINGTON “Lifestyle” only partially describes Marshall Lifestyle Medicine, founded by John Marshall Mullins, MD, in the fall of 2015. Mullins says that the term came into his head as he was searching for a way to describe the type of medical practice that he envisioned, one that would incorporate various and vital aspects of health, wellness, prevention, regeneration, fitness, spirituality, sexuality, and longevity. Mullins says that even before he knew that there was an emerging subspecialty called “lifestyle medicine,” he was creating the medical practice that pursues “living long and living well.”

The American Academy of Lifestyle Medicine describes six pillars of lifestyle medicine. They are nutrition, physical activity, stress management, restorative sleep, social connection, and avoiding risky substances.

Marshall Lifestyle Medicine’s 40+ page description of its purpose and services expands and expounds on those pillars as fundamental tenets and goals for patients and providers. Those services include hormone infusions, peptides, aesthetic products and services, care for sexual health, and regenerative and preventative medicine.

In the Beginning

To fully understand the creation and evolution of John Mullins, MD, and Marshall Lifestyle Medicine, it’s necessary to journey back to 1994. Mullins was an orthopedic surgery resident, fresh out of UK medical school. To pick up some extra money, he moonlighted as an ER doctor, hired over the phone by a staffing company. Mullins recalls being hired, sight unseen and unknown. “I was nothing more than a warm body to fill a shift. I was unqualified, and there I was.”

During an ER shift, Mullins ran into Jimmy Foster, MD, a classmate from UK,

“I believe that Marshall Lifestyle Medicine is the first in its category, so we are truly unique.”

-

John

Marshall Mullins, MD, founder, Marshall Lifestyle Medicine

in what became a “Steve Jobs meets Steve Wozniak” moment. In 1996, Mullins and Foster founded Marshall Emergency Services Associates, or MESA, in the spare bedroom at the apartment of one of their employees. They named it “Marshall” because that was a middle name serendipitously shared by Mullins and Frazier. They shared more than middle names though; they both recognized the need for change in the delivery of emergency medicine.

MESA became a success. Mullins and Frazier worked emergency shifts for days at a time. “We used to joke about how many days we went without sleep,” Mullins recalls. MESA recruited other doctors and was soon contracting with hospitals to staff their ERs. To say that ERs were the red-headed stepchild of a community hospital is an injustice to red-headed stepchildren. Mullins states, “The ERs were a community hospital’s nightmare. Most were understaffed, a drain on money and resources, a demoralizing and debilitating place to work.

Patient care was erratic and archaic. MESA took that burden off the hospital administration’s plate. We created a system of metrics where performance and accountability were demonstrable and repeatable in every hospital and community location.”

By 2013 MESA had contracts with 24 hospitals in Kentucky, Ohio, Indiana, and West Virginia. They employed over 400 ER doctors, APRNs, administrative staff, and hospitalists. Treating over 600,000 patients a year, the revenues exceeded $10 million dollars annually.

“It was hard work, but we were committed. Our staffing system worked. Our patient and customer satisfaction survey rates exceeded expectations. Community hospitals loved MESA. We kept growing while Jimmy and I continued to take our fair share of ER shifts, working 100 hours a week, holidays, weekends, overnights, along with everyone else,” says Mullins. “We were killing ourselves,” he says.

That changed in October 2013 when MESA was acquired for $115 million by TeamHealth, a physician staffing company with a national footprint. Mullins recalls the day the deal closed.

“I grew up poor. My family lived in South Dakota, and when I was 15, we moved to southern Kentucky. Most of my early life consisted of working to help out with family finances. My father was a truck driver. I mowed grass, shoveled snow, and worked fast food from sixth to twelfth grade. I worked so that I could have the necessities in life. All my life I had a goal to ‘make it’ so that my kids never had to struggle. I chased a dream of wealth and success and now at age 44 I have achieved that dream. But the night the deal with TeamHealth closed, I had never felt so empty,” says Mullins. “Empty and exhausted. I had achieved the success I had dreamed of, and it came at great cost — to my mind, my soul, my body, my relationships, my life.”

PHOTOS BY PAUL MARTIN

Marshall Lifestyle Medicine Starts… Slowly

For about a year and a half, from 2013 to 2015, Mullins pondered and imagined the future of healthcare and his role in it. He knew first-hand the underside of it: physician burnout, pre-authorization paperwork, delayed treatment, and declining reimbursements. He had lived in the belly of the beast. Now he was free to practice medicine the way he wanted to, but what did that look like, and how would that work?

“I was sitting in a primary care office, waiting to get something to help me sleep because years of overnight ER shifts had wrecked my sleep patterns. I had to wait three hours, thinking ‘how can this be a good system? If I had a job, how could I take off three hours for a fifteen-minute doctor’s appointment?’ It was the first time that I engaged the healthcare system as a patient, not as a doctor.”

“That’s when the term ‘lifestyle’ came to me,” says Mullins. “It just kept popping into my head. So, I developed a set of core prin-

ciples, foundational guidelines that were like what we did with MESA. I wanted healthcare that was accessible, attainable, with demonstrable results, scalable and repeatable for my patients who wanted to not only live long, but also live heathy, active, and fulfilling lives.”

Mullins infused his new medical practice with concepts he borrowed from the hospitality industry. Ambience. Patient comfort. Relaxation. How did the experience feel, as well as what were the results? He read The Happiness Project by Gretchen Rubin. He determined that his goal was not only delivering medical care to his patients, but also help them “feel good about going to their doctor, not because they were sick, but because they were healthy and happy.”

The first location of Marshall Lifestyle Medicine opened in 2016 on a busy commercial road in east Lexington, Kentucky. It looked like a spa with warm, rich colors, comfortable furniture, soft music and lighting, no sliding glass windows separating staff from the patients. The staff was trained

in hospitality. The practice business model was a combination of concierge, regenerative and preventative medicine all under a new umbrella he coined “hospitality healthcare.” He also opened a true “medical spa” where he was committed to raising standards in a very standardless field. The goal was to teach his patients lifestyle principles that would allow for a more balanced life. He wanted to help other busy professionals avoid the pitfalls of pursuing arbitrary finish lines while promoting prevention, early detection, and optimization.

Membership plans with various levels of physician engagement were created. Additional services such as nutrition, infusions, a fitness club, aesthetic procedures, sexual vitality, and more were designed by Mullins for those high-functioning individuals, male or female, who have achieved much success in their life, but were somehow losing their edge. “Something just didn’t feel right to these people. They were not living up to their own expectations and they were looking for

Sarah Clem, PA-C, and Meggan Freder, concierge coordinator and practice manager at The Spa at Marshall Lifestyle Medicine.

Marshall Lifestyle Medicine attracts high-functioning adults, evenly split between genders, with 38-44 being the largest age group.

an answer,” he says.

The first month that Marshall Lifestyle Medicine was open for patients, Mullins recalls that the response was a big fat zero, as in no patients! “I had spent over a million dollars building this medical office and training staff and we had no patients the first month. In the second month we had one patient, and two patients after three months,” Mullins says. “Eventually, patients found us, and confirmed our belief that there was a need and desire for our kind of medical practice. Patients just didn’t know it existed yet… until it did.”

Eight Years Later and Growing

From that inauspicious opening, Marshall Lifestyle Medicine now has three Central Kentucky locations, two in Lexington and one in Georgetown. Mullins says that the concierge, direct pay, patient to doctor, no-insurance model is working well now, and he has nearly capped out at 400 patients at each location, which is the number where the practice is profitable, but the patient experience is maintained. Mullins sees patients three days a week, Wednesday through Friday, approximately 8–12 patients a day. Most of the patients come to the practice once a week for a consultation, a treatment, an infusion, or an aesthetic procedure. All his patients have his cell phone number and can reach him for urgent care needs, advice, ER avoidance, or simply to talk. When needed, patients are referred to specialists. Advanced diagnostic screenings are routinely part of the prevention care model.

Always a student of metrics, Mullins confidently states that the average age of his patient is 48 years old, with 38- to 44-yearolds being the largest cell. The genders are split equally 50-50 and 90% are couples. “No matter which spouse comes in first, the other spouse soon follows,” he says. “It’s inevitable that when one spouse sees the results of our approach to health and lifestyle, they want to be part of it as well.”

In August 2024, Marshall Lifestyle Medicine will open its first location in Louisville. It is a continuation of Mullins’ plan to open multiple locations throughout the

Kentuckiana and Ohio regions, duplicating the roadmap and success of MESA. Mullins is actively recruiting doctors to join the Marshall Lifestyle Medicine team. “My first option are ER doctors because I know them. I know how they think, how they can multi-task and are results driven. I’m also interested in residents who want to have the work-life balance and patient interaction that we offer. We develop personal relationships with our patients, which are difficult to build when you see 40 to 50 patients a day, as is the case in most primary care offices,” says Mullins.

“I believe that Marshall Lifestyle Medicine is the first in its category, so we are truly unique,” he says. “We have a high access-to-physician model. We use a hospitality approach to make our patients feel comfortable, using their words to engage with them. We meet people where there are in the moment when they walk into our practice. We don’t try to change them overnight, but we give them a structure and path to better health, vitality, and prosperity.”

Mullins stresses that Marshall Lifestyle Medicine diverges from both direct-pay traditional medicine and esoteric lifestyle medicine approaches, which he says the public is not yet ready for. “We offer improved provider access for a fee, and our focus is on preventing what’s preventable and detecting what needs to be detected early, and optimizing everything else,” says Mullins. “We have testing for the one-offs because there’s always the outlier.

Our goal is optimizing health-span — a life free of disease and disability.”

The Doctor’s Doctor

Mullins recalls his three-hour wait in the waiting room, saying “When doctors treat other doctors as patients, they treat them with deference. When I was sitting in that waiting room, they didn’t know I was a doctor, so I was treated like a normal patient. It blew my mind. That’s when I knew I had to reinvent how healthcare was being delivered.”

Physician burnout is rampant with physician suicide ever-increasing. Mullins believes that the Marshall Lifestyle Medicine approach to a doctor’s own physical and mental health can help turn the tide. “We attract high-functioning individuals and executives, like doctors, who have made a million small decisions in their lives to get where they are now. Now we give them the choices, the structure, the engagement, and the accountability to live the healthy and fulfilling life they want to live for the rest of their lives.”

“Everything I do is to raise standards, to be above reproach. That’s my litmus test for every decision concerning Marshall Lifestyle Medicine, ‘Are we raising standards? Is it defendable? Is it good healthcare?’”

Mullins says the Lexington experience has told him that his vision is what people want in healthcare. Now he’s ready to take it on the road.

PHOTO BY PAUL MARTIN

LOUISVILLE When it comes to treating gastrointestinal issues, the key to success for Kristine Krueger, MD, is helping patients understand the interconnectedness between gut health and their overall health.

Krueger, the Nancy Middleton Smith Professor at the UofL School of Medicine and the chief of academic and clinical affairs for gastroenterology, hepatology and nutrition at UofL Health – UofL Physicians, says that the calling to help others and teach about the science behind all aspects of medicine is something that she’s had since childhood.

Krueger, who earned her BS in biology and chemistry at Florida State University, received her medical degree at the University of Florida before doing her residency at the Medical University of South Carolina Medical Center.

The daughter of an Air Force engineer and pilot, Krueger says she grew up in a military family and moved frequently. When her father was stationed in Vietnam, her mother took a job as a nurse. Fascinated by the stories her mother was telling her, she fell in love with medicine.

“I wanted to do medicine because I liked biological sciences and the body,” she says.

The

Importance of Gut Health

Research into GI health, diet, and exercise are top priorities for UofL Health gastroenterologist

BY LIZ CAREY

“Then Mom said, ‘Well, you don’t want to be a nurse, you want to be the one making the decisions. You want to be a doctor.’ And I decided she was right.”

Krueger says that her practice at UofL Health is separated into the administrative functions of running the division, including hiring doctors and teaching medical students, plus spending time with direct patient contact. Patients run the gamut from highly complex diagnoses that require hospitalization to patients needing endoscopy, she says.

More and more, Krueger says, her patients are younger, a trend seen nationwide.

A Changing GI Patient Population

According to a report published in JAMA Network Open, gastrointestinal cancers, including colorectal, pancreatic, and bile duct cancers, are presenting in younger adults more often than they were a decade ago. The study, “Patterns in Cancer Incidence Among People Younger Than 50 Years in the US,” published in August 2023, found that between 2010 and 2019, early-onset cancers in people under the age of 50 increased by 0.74 percent. The study

PHOTO BY JOHN LAIR

also found that early onset gastrointestinal cancers had the greatest increase during that time (from 6,431 cases in 2010 to 7,383 cases in 2019), and incidents of those cancers rose the fastest, at a rate of 2.16 percent annually.

As a young parent, Krueger says she recognized a link between what children are being fed and health complications later on.

“When I had my own children, I became very much interested in childhood nutrition,” she says. “I was just appalled at kid’s menus, how they were 50 percent fat, and this concept of there being ‘kid food’ versus ‘adult food.’ I knew right away that didn’t make any sense from a science standpoint… the kid learns bad habits that will correspond down the road to type 2 diabetes, obesity, and other health problems.”

Additionally, Krueger says, younger people are not as healthy as they were decades ago.

“They’re 20 years old, but they can’t jog a half a mile before getting short of breath,” she says. “They don’t go outside and play sports anymore. They’re sedentary. They eat too much fast food. They sit in front of the TV and eat, which makes them overeat, which contributes to all those diseases that we talk

about — accelerated atherosclerotic heart disease, diabetes, and cancers. And we really don’t know why. We don’t have the exact answers, but we see the trends.”

Research in Microbiota

Researchers in gastroenterology have begun to identify some causes, Krueger says, like fermented products in the digestive system and their damaging effects on the mucosa in the digestive system, among others. Research into the impact of GI health on other aspects of health is ongoing, she says.

Other developments include looking into the microbiota within the body and how it affects other aspects of health. Researchers are also studying issues like firmicutes, bacteroides, and other viruses in the GI tract and their impact on health.

“The science is now looking at how your gut bacteria influence neurodegenerative diseases,” Krueger says. “Some folks are looking at autism, Parkinson’s disease, and MS, and how the microbiota is different in these diseases.”

As a cyclist, she was particularly interested in research that has identified a particular bacterium that allowed some cyclists to extract more energy from the food they eat and have better performance or endurance. In another study, a childhood disease called PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) was found to have been caused by a chronic streptococcal infection that altered behavior in children.

“When they found out that they had a chronic infection that crossed the blood-brain barrier, and that with effective antibiotic treatment it was normalized, that opened up a lot of people’s eyes to the concept that the microbiome has a lot to do with your overall body’s health, including your brain,” Krueger says. “We need more doctors to be on the side of ‘That’s interesting. I’m going to be open-minded to seeing what we can do.’”

Traditional, Complementary, Alternative, and Innovative

Some of the treatments, while FDA approved and effective, may not be completely accepted, Krueger says.

“When the FDA approved fecal transplants for C. diff (Clostridioides difficile) diarrhea… it worked twice as well as vancomycin, the current treatment,” she says. “It cured people that were going to die from C. diff. That has been the single most impressive medical advancement in GI in my career. And that is just astounding, because it doesn’t follow any of Koch’s postulates. You’re giving billions of someone else’s germs, basically bacteria, fungus, viruses, and you’re sticking them in a host who’s sick… and within 48 hours, they’re off their pressors. To me, that was just an absolute astounding discovery. And still, a decade later, we have doctors who say that it’s barbaric.”

Looking at new findings, as well as at complementary and alternative medicines, she says, is an important part of treating the whole patient. Treatments from ancient medical procedures from China or Ayurvedic medicine from India give patients more decision-making authority, Krueger says, and are more cost-effective in some ways. It is also practical to address those treatments because some patients will already be using them, and not acknowledging them can disrupt a more traditional treatment.

“You have to be open-minded because if you aren’t and you don’t ask patients what they take, they’re not going to tell you what they’re doing,” Krueger says. “Then when they’ve had their liver transplant but they’re taking St. John’s wort, it will interfere with their immune-suppressants and they reject their liver. People are going to seek alternative therapies that are less expensive, less of a hassle and don’t require a copay. You need to be aware of those factors in your particular specialty.”

By creating a direct bond with her patients and understanding them as human beings, Krueger says she can help guide them to better healthcare choices that are personalized for them and their needs.

Working with them for positive outcomes, she says, is what drives her.

“I think the ancient art of healing patients is a calling that you are driven to,” Krueger says. “Maybe it’s selfish, but when you come home at night, even after a busy day… the smile on a patient’s face when they say, ‘Thank you, doctor’ will melt your heart and you want to do it again and again and again.”

A Sterling Achievement

Urologist Ray Brenton Terrell passed up a potential athletic career, but finds himself still in the game 27 years later

BY JIM KELSEY

MOUNT STERLING In baseball, there’s no better feeling than rounding third and heading for home to score the game-winning run. It is a feeling Brent Terrell, MD, felt many times, first as a high school baseball star at Morgan County High School in eastern Kentucky and then as a member of the baseball team at Georgetown College.

But baseball was far from Terrell’s only interest. By the time he was in junior high school, he already had an interest in medicine and perhaps becoming a doctor. Both those dreams remained very much alive until he faced a moment of truth in college.

“I remember I was at Georgetown College, having the tough decision whether to go on the

spring baseball trip or to stay home and prepare for the MCAT,” Terrell recalls. “I chose to stay and prepare for the MCAT. If it hadn’t been for this absolute preset path I had in my mind, I might have considered making a run in the minor leagues. But I knew there was something else I had to do and if I did anything else it would take me off track, so I had to sadly walk away.”

After Georgetown College, Terrell went to the University of Kentucky College of Medicine, followed by a urology residency at the University of Iowa Hospitals and Clinics. Urology was not his first choice, but ultimately it was the right choice.

“I had laid the groundwork to pursue another surgical subspecialty, but I realized that my choice was not what I wanted to do,” Terrell says. “I had a medical school colleague

who was going into urology and he encouraged me to look into urology. Once I did, I fell in love with it.”

Terrell found that urology fit many of the things he enjoyed most about practicing medicine. He appreciated the academic and research components of urology combined with the practical and surgical applications. He also found the universal need for urology to be very rewarding.

“Urology is underappreciated until you need it,” Terrell says. “Most people are going to need

A star on the Georgetown college baseball team, Dr. Terrell pursued a medical career over a shot at the major leagues.

PHOTO BY GIL DUNN AND PROVIDED BY BRENT TERRELL, MD

CHI Saint Joseph Medical Group urologist Ray Brenton Terrell, MD, at his new office in Mount Sterling, Kentucky.

it at some point in their life, kind of like a plumber. I always say we are human plumbers.”

Returning to His Roots

After his residency in Iowa, Terrell came back to set up a solo practice in Mount Sterling, Kentucky, in 1996. He maintained that solo practice for nine years before expanding his scope of work to locations such as hospitals large and small, outreach clinics, and ambulatory service centers. Throughout his career, he has stayed in Kentucky and has maintained a presence in Mount Sterling.

On January 15, 2024, he returned to his roots, when he joined CHI Saint Joseph Medical Group in Mount Sterling.

“That community has been in my blood for 27 years,” Terrell says. “I have always maintained some scale of practice there. Now I feel like I’m home and am getting back to my roots. It feels full circle.”

At age 61, Terrell is as passionate as ever about urology, but he has also embraced the need for more work/life balance. He estimates that he works about 40 hours a week now and is off at least one week per month. Terrell lives in Lexington and drives 45 minutes to Mount Sterling daily.

“I think everyone has had an awareness of a different work/life balance paradigm,” Terrell says. “My practice has evolved about 180 degrees over the last 27 years, but the fact that I’m able to still stay in the profession is a testament to how we have all evolved and have become more understanding of different ways of doing business. I’m in a different practice model than I’ve ever been. I hope it’s going to provide me some longevity to practice as long as I’m physically and mentally sound.”

A Broad Patient Population

Today, most of Terrell’s practice involves outpatient surgical procedures. Contrary to the misconception that urology is just for older men, Terrell sees patients of all ages and demographics, both men and women.

“We all have urologic problems regardless of our age, sex, or other demographics,” Terrell says. “Men and women and children all experience similar overlapping urinary

tract disorders. These disorders can present in a variety of ways, such as stones, blockages, bleeding, tumors, and infections, to name a few. We work to serve everyone, and it brings me great joy to do so.”

Terrell says that he has a special interest in the diagnosis and management of prostate cancer. Over the course of his career, he has seen the advancement in prostate cancer screening, including the early days of prostate specific antigen (PSA) screening tests, and more recent developments in prostate cancer detection and cancer risk assessment. Prostate cancer treatment used to involve aggressive radiation therapy, open prostate removal, or surgical castration. The options were few and foreboding. Now, the surgeries are minimally invasive through the use of robotics, and radiation techniques are more targeted, safe, and effective. CT scans, MRIs, and PET scans have all become essential tools in managing prostate cancer and customizing treatment options.

“We are now able to take prostate MRI data into a procedural setting where we fuse those images with real-time ultrasound to allow precise targeted biopsies,” Terrell says. “Even in advanced prostate cancer, we have enhanced treatment options that allow, in many cases, prolongation of life and improved quality of life.”

Terrell cautions that, despite the advancements, prostate cancer remains a serious medical condition.

“One of my missions is to get the word out that this disease is still there and it’s very prevalent,” he says. “It’s still a killer, but we now have better ways to tailor the detection and the treatment and we are moving more and more toward lesser invasive modalities with lesser comorbidity and risks from those modalities.”

Having always enjoyed the research and technology components of medicine, Terrell is especially excited to see the advancements in detection and treatment that promise better outcomes for his patients.

“This is kind of a golden time for us in the profession, and that’s one of the reasons I stay in it,” Terrell says. “I think we have a lot of room in Central Kentucky to advance and do better for our patients. We are all patients at some point in our lives, and I enjoy the patient interaction. I hate to see anybody suffer and I sure don’t want to see more prostate cancer coming through my clinic. I can’t help that, but what I can do is to be their teacher and advocate at all points along the way.”

Rural Care Is Needed

It is not lost on Terrell that he is often among the few options for the rural patients in his area. Healthcare provider shortages are particularly unsettling to rural and underserved populations, such as those areas in and around his hometown.

“You don’t have to look very far to find people that are underserved,” he says. “For twenty years I would drive to West Liberty and do a clinic, and they still don’t have urology there. We are dealing with more underserved areas now than we ever have. Bringing healthcare to the public and making it as convenient for them as possible is something that I have always prided myself in. It gives me a lot of joy to be the person to do the driving and for me to be the one that makes the effort to be there for people who have shaped who I am as a human and as a provider. For me it’s been a call to service.”

It is a calling that he still heeds. He keeps working because his patients need him, because he loves caring for them, and because he knows what he’s doing.

“I still have a passion for what I do. I haven’t lost the spark and I hope I don’t for quite a while,” Terrell says. “Getting back closer to my roots, my home, is also adding more wind to my sails. I feel like I’ve got some good to do and I get joy out of that. I hope in the process of that, I benefit somebody.”

Spoken like a true teammate, still playing for his team and his love of the game.

Screen Time

Gastrointestinal medical oncologist Michael Driscoll, MD, is passionate about the power of screening

BY JIM KELSEY

LOUISVILLE Not all screen time is bad — not the type of screen time that gastrointestinal medical oncologists like Michael Driscoll, MD, advocate for. On the contrary, Driscoll, who is the director of the Gastrointestinal Malignancy Program for Norton Cancer Institute, which is part of Norton Healthcare in Louisville, eagerly encourages some potentially life-saving screen time.

“Norton Healthcare really has gone to bat trying to improve colorectal cancer screening rates around the Commonwealth,” says Driscoll, who joined Norton in 2011. “They’ve partnered with the surgeons and the gastroenterologists here to really push for colonoscopy screenings by making availability much better. They’ve gone also to Frankfort trying to improve legislation and to get the payers to have easier access to colonoscopies and colorectal cancer screening. It’s definitely not by happenstance that Kentucky is near the top for colorectal cancer screening.”

Driscoll notes that Norton offers Saturday colonoscopies, enabling more people to be screened without missing work.

“The best screen is the one that you get,” says Driscoll. “If they’re getting them in the right patient population and on time, then it ultimately will decrease people’s risk of dying of this cancer and developing these cancers at later stage or being found at a later stage, which has a worse prognosis.”

The Norton Cancer Institute

Fortunately, the prognosis is not always right. After all, what were the odds that Driscoll would wind up in Louisville? Having grown up in a suburb of Boston and attended Colorado State University majoring in molecular biology, he hadn’t planned on going to medical school. But with an interest in microbiology and working in cancer research

after graduation, plans changed. A year later, he was admitted into medical school at LSU.

“I could see the way the world of medicine was going, and everything has gone more molecular and more genetic,” says Driscoll, explaining his ultimate specialty area.

Driscoll’s wife is from Louisville, so he accepted a fellowship at the University of Louisville. The rest is history.

“In the Norton Cancer Institute, we’ve come to the conclusion that oncology is growing at such leaps and bounds that it’s difficult to keep up on everything going on in oncology,” says Driscoll. “We decided that it was in our, and our patients’, best interest to try to subspecialize in different fields within oncology. So I decided to get into GI oncology at Norton.”

A typical day for Driscoll starts with rounding on a few patients in the hospital before going to the clinic, where he sees patients all day long with the assistance of a nurse practitioner and a nurse clinician. He is also typically on call during the week as well as weekend.

“We also see patients that are on active chemotherapy all day long, every day,” says

Driscoll. “Depending on what stage they are or what type of cancer they have, we may take their cases to the multidisciplinary conference where we bring up their imaging on the big screen and we talk with surgical oncology or maybe interventional radiology.”

The collaborative efforts don’t end there. A lower GI tumor board and an upper GI tumor board, which meet on separate days, allow for a group discussion to determine the best course of care for each patient.

“We can present all their information, present their cases, look at their imaging, talk with the surgeons, talk with radiology, talk with pathology, medical oncology, interventional, and come up with a game plan right then and there and then go see the patient,” says Driscoll. “Our nurse navigators help set up the plan as we put in orders, getting the patients through the system as quickly as possible. It really has improved the quality of the care of GI malignancy patients significantly.”

Driscoll sees patients ranging in age from their mid-20s to 80s and 90s. Patients who were not diagnosed via screening often present with stool caliber changes, blood in the stool,

Michael Driscoll, MD, is director of the Gastrointestinal Malignancy Program at Norton Cancer Institute in Louisville.

PHOTO BY JAMIE RHODES

constipation, abdominal pain, and bloating. “They may also have weight loss and a constellation of things that is usually from a tumor blocking their gastrointestinal tract,” says Driscoll.

Driscoll notes that in the last 10 years there has been a 20 percent increase in people younger than 50 years old being diagnosed with colorectal cancer. Theories for the causes of the increase include obesity, sedentary lifestyles, processed meats, and other foods. The focus on screening at earlier ages also plays a part.

“We are screening people at younger ages with no personal family history of colorectal cancer and no symptoms. Many of us think that we may even need to be screening younger,” says Driscoll. “Ideally what we want to do is find these patients before they develop cancer. The reason why we have screening tests is to find something before it becomes a big problem. The majority of colorectal cancers will arise from a polyp, and the time to do something about it is when it’s in the polyp

stage. So as the saying goes, the best time to treat a cancer is before it starts. If they have a polyp that has a malignant potential, the best thing is to get it removed. That’s why colonoscopy is the gold standard for screening.”

Driscoll says that the fecal immunochemical tests such as Cologuard that are frequently advertised look for blood in the stool.

“When you listen to the commercial, they say it’s 92% effective detecting colon cancer,” says Driscoll. “The flip side of that coin is that it misses 8% of all colorectal cancers. Another statistic they don’t tell you is that it misses 50% of all polyps. But a colonoscopy is both diagnostic and therapeutic. They can remove the polyp before it becomes a cancer.”

Delivering the News. Creating and Working a Plan.

For patients who do have colorectal cancer, Driscoll recognizes the diagnosis can be devastating news. But it doesn’t have to be the end of the world. Helping patients cope with that reality and come to grips with the journey

they face is central to his initial meeting with those patients.

“I ask them how much they know, and they usually tell me either nothing or very little,” says Driscoll, who is intentional about communicating with patients in language they can understand. “We formulate a game plan and make sure that everybody knows what it is that they have, what the options are for treatment, including side effects, risk benefits, and then get things executed as quickly as possible.”

Driscoll says that screenings for other gastrointestinal cancers such as pancreatic cancer are not yet where they need to be in terms of effective advanced detection. But ongoing research and trials promise to bring about better methods for screening.

“Oncology screening has significantly improved, especially with colorectal cancers and potentially upper gastrointestinal cancers,” says Driscoll. “I think part of the future of oncology will be MCEDs or multi-cancer early detection assays. There is one called GRAIL, which is probably one of the more prominent ones, and they can actually screen for many, many different cancers with one test. These would be blood tests that they actually can look for certain genes that are modified and they can pick these up in the bloodstream, which could indicate that you could have a cancer trying to develop in you.”

Part of Driscoll’s work to stay ahead of the curve involves being active in clinical trials, which he says is wholeheartedly supported by Norton Healthcare and the Norton Research Institute. “It’s the right thing to do for the patient,” says Driscoll. “We give them options for treatment and potentially access to other medications and new targeted treatments that they wouldn’t otherwise have access to.”

Driscoll, whose aunt died of colon cancer, is passionate about finding better screenings and more effective treatments.

“It’s an exciting time to be in GI oncology, even though we have to give people occasional bad news,” he says. “What keeps us coming back to work is those days when you’re giving people the good news. You go through this cancer journey with not only just the patients, but all their family too. It’s a responsibility that we have.”

Eating Disorders in Kentucky

We need to take a new look at a growing problem

BY ZUBI SULEMAN, MD

LOUISVILLE There is a growing concern about the increased prevalence of eating disorders and limited resources to treat these disorders in the state of Kentucky. Further, there are many misconceptions and myths about eating disorders.

Eating disorders (ED) are serious mental illnesses characterized by disturbances in behaviors, thoughts, and feelings towards body weight, shape, and/or food and eating that have a substantial impact on the well-being and quality of life of the person experiencing the eating disorder.

Currently, there are roughly 900,000 individuals, of which 29,000 are children, struggling with an eating disorder in Kentucky. In Louisville, there are approximately 200,000 individuals with ED. These individuals range as young as five years old up to 80 years old with all genders and sexual orientations, across all socioeconomic groups, and from different cultural backgrounds.

According to the Academy of Eating Disorders, nine percent of Kentuckians, approximately 393,345 people, will have an eating disorder in their lifetime. The yearly cost of ED to the economy and society in Kentucky is approximately $883.7 million, with a further breakdown into the cost of ED visits to be over $400 thousand and for inpatient hospitalizations to be $2.9 million.1

These individuals require close monitoring due to serious medical complications that frequently result from disordered eating behaviors.

A National Problem

Statistics show that in the United States there are 10,200 deaths annually as a direct result from an eating disorder, which equates to one death every 52 minutes These numbers reflect the seriousness of these disorders.2, 3

There are significant gaps and barriers in Kentucky for treating eating disorders.

There are very limited treatment options, currently only two IOPs and 1 PHP available for patients. There are no eating disorder psychiatric residential treatment facilities in the state. Individuals who are struggling with ED are required to travel out of town or state to receive treatment.

Another barrier to treatment in Kentucky is insurance. Individuals with Medicaid are limited to almost no options for higher level care outside of the state. There are no established aftercare programs or step-down care available in Kentucky. Many private insurances will cover a patient’s treatment based on BMI only. In addition, clinicians and practitioners are not fully aware of the commonality of ED. As a result, the limited practice of ED screenings can lead to prolonging the diagnosis, prompting more serious complications and risks for the individual.

Another misconception about eating disorders is the stereotypical image that someone with an ED must fit. It is misleading to believe that a person must look a certain way or be a certain size to have an eating disorder,

or to rely solely on BMI for a diagnosis. In reality, we are seeing more atypical anorexic patients now compared to classic anorexia nervosa.

Individuals with atypical anorexia have a normal or high BMI; they have a higher body weight and become preoccupied with their weight or shape. They will lose a considerable amount of weight, putting them at a risk for malnutrition and starvation. Their weight can drop from the 95th percentile to the 50th percentile, which may still be considered within the normal limit, but it causes severe malnutrition. This is why it is highly recommended to use other health metrics, along with BMI, when treating individuals with eating disorders.

Recently, there have been increased discussions about glucagon-like peptide-1 receptor agonists (GLP-1As) being used as approved or as off-label treatments for weight loss. At the same time, concerns increase about the potential for GLP-1As to impact eating disorder symptomatology. Preliminary research on the use of GLP-1As to treat binge eating has been conducted; however, studies have design limitations and additional research is needed.4

Even with current limited evidence, it is very possible that the use or discontinuation of GLP-1A could exacerbate or contribute to the development of disordered eating behaviors and can negatively impact their treatment. It is extremely important to screen for a history of eating disorders, active eating disorders, and/or vulnerability for an eating disorder when prescribing these medications.

The Stigma of Eating Disorders

Despite increasing efforts to raise awareness for eating disorders, there remains a lack of knowledge and persisting misconceptions about its seriousness. Individuals who grapple with the devastating reality of an ED also face the additional stress and challenges of the serious stigma that presents with it. The

PHOTO BY TRACIE DILLON

Zubi Suleman, MD

stigma attached to these disorders can have significantly negative consequences for the lives of these individuals.

In many cases, social media promotes harmful behaviors and mindsets that can lead to an eating disorder. Research suggests that eating disorders attract more stigma compared to other mental health disorders, such as anxiety or depression. Negative attitudes towards eating disorders are pervasive among the general population, within employment and education institutions, within health services, and even among the friends and families of people experiencing eating disorders.5

It is important to create a weight-inclusive environment that is friendly and respectful to all individuals regardless of their weight, shape, or size. Further work needs to be done to remove the negative attitudes, beliefs, and discrimination against individuals with higher weights. This includes “the development of public campaigns and initiatives to raise

awareness of eating disorders, the development of guidelines for the reporting and portrayal of eating disorders in communication mediums, the establishment of advocacy groups and organizations, and the inclusion of lived experiences within policy development, service design and delivery and organizational governance.”6

Recovery from an eating disorder is a longterm process, and it involves overcoming both physical and psychological problems related to it. Early interventions and prevention can play a vital role in significantly reducing the complications and aid in recovery. We all have a role to play in reducing the stigma and discrimination. We also need to strive to increase early screening, ask more questions about eating habits, and promote good health, without the focus of weight management. Together, these steps will aim to reduce medical complications and promote recovery for individuals with an eating disorder.

Zubi Suleman, MD, is a board-certified and distinguished fellow of APA, practicing as an adult psychiatrist at the RRVAMC. She is the KPMA president and an assistant professor with UofL Department of Psychiatry. She is an active member of the Kentucky Eating Disorder Council and chair of the Health Service Provider Education Committee.

REFERENCES

1 www.nationaleatingdisorders.org

2 www.hsph.harvard.edu

3 ANAD.org

4 pubmed.ncbi.nlm.nih.gov/38135891

5 pubmed.ncbi.nlm.nih.gov/31711324

6 NEDC

Lexington

Patricia Morgeson (859) 519-3369 NMLS ID # 827418

Louisville

Gary Spence (502) 588-1595

NMLS ID # 1087080

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Things I Learned at the KPMA 2024 Annual Conference

BY JAN ANDERSON, PSYD, LPCC

LOUISVILLE When Ali Farooqui, MD, told me he wanted to expand psychiatry beyond its traditional boundaries, he meant it.

He organized the 2024 KPMA conference, to expand psychiatry into “a whole-person approach to mental health that includes brain health, body health, family health, and nutritional health.”

Here are some key takeaways from the conference:

Nutraceuticals

and Phytoceuticals in Psychiatric Practice: G. Randolph Schrodt, MD

If you took a vitamin this morning or one of your patients took a supplement last night, pay attention. They’re not backed by hard science or regulated like psychiatric prescription drugs, but over-the-counter supplements and herbal products are big business, widely advertised, and used by patients for psychiatric symptoms. What makes it complicated is that: a) some of these products live up to their claims (when not misused); b) doctors don’t get much formal training about how to navigate the hype and safely integrate the effective products into clinical practice. Some of the OTC treatments who have earned a place in psychiatric settings include:

1. St. John’s wort: Studies show that the psychoactive compounds in St. John’s Wort are superior to a placebo for treating mild to moderate depression and not significantly different from comparative SSRIs.

2. Omega-3 fatty acids: As an antineuroinflammatory, Omega-3 fatty acids enhance neural and synaptic plasticity and have an anti-depressive effect.

3. Vitamin D: Low Vitamin D is associated with depression, anxiety, and seasonal affective disorder (SAD).

4. Magnesium: Magnesium is associated with significant reductions in depression scores.

5. N-acetylcysteine (NAC): By regulating glutamate levels in the brain, NAC appears to be effective in treating depression, bipolar disorder, and moderate to severe OCD and may relieve seasonal affective disorder. NAC may also have applications in treating substance use disorders. Preliminary studies show that NAC may decrease cannabis and nicotine use and cravings.

Endocrinology and Mental Health: Omalara Fakunle, MD

MD

Dr. Fakunle shed light on the complex interface of common endocrine issues and mental health. Thyroid disease can manifest with personality changes, dementia, and aggressive behavior. Patients with subclinical hypothyroidism often experience depression. “Screen for thyroid disease, but also look for other potential causes. It’s easy to misdiagnose when patients report nonspecific symptoms like fatigue.”

Dr. Fakunle described GLP-1 potential to reverse psychotropic-induced obesity and hyperphagia associated with antipsychotic medications. In addition, GLP-1 may address cognitive deficits that are not alleviated by antipsychotics.

Nutrition and Mental Health Implications: Vanessa Oliver, RD, LD

Vanessa

“People walk in to see the dietician and expect me to be this no-nonsense, white coat-wearing ‘step on the scale’ person who says, ‘Stop eating sugar and go lose 25 pounds.’ I am not that person,” Dr. Oliver said.

You’re always going to see the top 10 list of foods that you should absolutely eat to be healthy or that you should never let pass your lips. But it’s not an “Eat this, don’t eat that” scenario, which is how it’s often presented. These are black-and-white thinking traps. It’s more about consistent behavior, focusing on your overall diet.

Ali Farooqui, MD

G. Randolph Schrodt, MD

Omalara Fakunle,

Oliver, RD, LD

Substance Use Disorders Treatment Update: James Hawthorne, MD

Suboxone and buprenorphine disorder treatment is shifting from stigmatization to acceptance in Kentucky.

“These treatments have been shown to be life-saving, yet they are still stigmatized in some circles. It’s important to make them more accessible.”

Dr. Hawthorne discussed regulatory issues related to buprenorphine prescribing and shared various strategies for buprenorphine initiation, including standard in-office induction, at-home induction, and low-dose initiation. He also discussed the use of long-acting injectable buprenorphine in the treatment of OUD.

Treatment of Methamphetamine Use Disorder: Jonathan Martin,

MD

You can never write anyone off or assume anything.

“I think the most surprising thing I’ve learned about working in the field of addiction medicine is who you end up seeing using substances. It’s not what you expect. I’ve had grandmas, CEOs, lawyers, doctors, and then the people you would normally expect.

Dr. Martin discussed the expected time course of methamphetamine-induced psychosis and explored treatment options and efficacy.

Psychopharmacology UpdatePromising New Treatments for Depression: Brian Casey, MD

“After several years, we’re finally seeing some breakthrough treatments for depression beyond SSRIs.”

Dr. Casey highlighted the standout features of new antidepressants:

• Gepirone: An antidepressant that doesn’t cause sexual dysfunction.

• Ketamine: An antidepressant that works faster and offers more than SSRIs. It

triggers the formation of new, healthier neural connections in the brain and may repair damage to the brain’s proteins caused by stress hormones.

• Esketamine: An antidepressant that shows promise for treatment-resistant depression unresponsive to SSRIs.

• Zuranolone: The first pill for postpartum depression (PPD). It works quickly and stabilizes hormones rather than serotonin levels.

An Alarming Increase in NonSuicidal Self-Injury in Adults: Chelsea Atwater, DO

Chelsea Atwater, DO

“We’ve seen a very large and sudden increase in the prevalence of nonsuicidal self-injury (NSSI) since the pandemic, especially in adults…. I don’t know that we have much training in how to treat it.”

Dr. Atwater emphasized the strong correlation between NSSI and suicide completion rates and discussed the current best practices for NSSI, including prescription, complementary, and alternative interventions.

Criminalizing Patients with Schizophrenia Can Lead to a Cycle of Noncompliance and Reoffending: Kelsee Crawford, PharmD

“It’s one of the disease states that often gets criminalized when they’re just extremely sick patients. We know that patients with any disease type are not going to take medicine the way they should. … It’s important to find a medication that they’re willing to continue taking so they can live a normal life, have stable relationships, and stay out of the justice system.”

Exploring the Intersection of AI, Psychiatry, and EHR: Rian Kabir, MD and Nathan Aquino, MD

Dr. Kabir provided a big-picture perspective of AI’s remarkable potential to transform healthcare and its hair-raising risks.

Rian Kabir, MD Nathan Aquino, MD

Dr. Aquino homed in on AI integration as a game-changer for EHR systems to enhance documentation accuracy, coding, and clinical decision support and unlock the power of predictive analytics to improve patient outcomes and streamline care.

KPMA Leadership: Forging the Future. A Lifetime Achievement Award for Rif El-Mallakh, MD

Rif El-Mallakh, MD

“Dr. Rif El-Mallakh is a triple threat,” according to colleague Kathy Vincent, MD. “He is an education expert, he has extraordinary teaching skills, and he also has a real passion for research.”

A Focus on Advocacy: Ruchita Agrawal, MD

Ruchita Agrawal, MD

“I want to focus on advocacy. We are not very good lobbyists, and our patients need so many medications that Medicaid and insurance providers do not cover.”

A Focus on the Deadliest Mental Disorder - Eating Disorders: Zubi Suleman, MD

Zubi Suleman, MD

“We don’t ask those questions, and people are not willing to tell us what’s going on with them. Ask about past body dysmorphia behaviors. Ask about restrictive eating behaviors. Offer patients a blind weight where they’re not facing the scale.”

James Hawthorne, MD

Jonathan Martin, MD

Brian Casey, MD

Kelsee Crawford, PharmD

HumankindnessGala

We are excited to share the news of our 2nd annual Humankindness Gala. This year ’s event will pay tribute to the late Jeff Murphy, former Division Vice President of Marketing and Communications for CHI Saint Joseph Health, and his love for the arts.

The five CHI Saint Joseph Health Foundations will come together at the Marriott Griffin Gate in Lexington, May 18, 2024, to recognize our physicians, employees, and advanced practitioners of the year. Additionally, we will showcase some of the aesthetic contributions of art in and around our local community hospitals.

We invite you to join us for this special occasion as we recognize Humankindness and the power of art in our world. Enjoy an evening that will feature dinner and dancing to The Best Kept Secret band. The gala will include recognition of local artists as well as a silent auction.

More information can be found at supportchisaintjosephhealth.org/news-and-events/ humankindness-gala

The

Saint Joseph London Foundation

Saint Joseph Mount Sterling Foundation

Scan QR code for direct access to the gala website.

Flaget Memorial Hospital Foundation

Best Kept Secret

CHI Saint Joseph Health – Cancer Care in Lexington Adds Seasoned Physician

LEXINGTON CHI Saint Joseph Health – Cancer Care in Lexington welcomed Nicola Jabbour, MD, to its team of caregivers. Jabbour has practiced oncology and hematology in Hazard and Danville for nearly fourteen years.

Jabbour grew up in Syria, where his father and several uncles, cousins, and other family members were physicians. Jabbour obtained his medical degree from the University of Tishreen in Latakia, Syria, before pursuing further training in the United States. He completed his internal medicine residency at the University of Illinois at Chicago, followed by a fellowship

in hematology/ medical oncology at the University of Connecticut.

In addition to his clinical practice, Jabbour has contributed to medical education through teaching roles in Hazard and at the University of Kentucky.

Pediatric & Adolescent Associates Joins Lexington Clinic

LEXINGTON Pediatric and Adolescent Associates (PAA) and Lexington Clinic are pleased to announce a partnership to enhance primary care options for young patients in Central Kentucky.

“We’re very excited to welcome Pediatric and Adolescent Associates (PAA) as a part of Lexington Clinic. In addition to expanding our care to patients in the communities we serve, this partnership fits with our mission to provide excellent, equitable, value-based care while helping to improve the health of all children and adolescents,” said Dr. Stephen J. Behnke, CEO of Lexington Clinic.

This partnership should have little to no impact on current PAA patients, as they will not see any difference in how the multi-site

practice operates. “While there may be certain updates carried out at our facilities, I can assure our patients that the type of care they receive will stay the same at both our locations,” said Dr. Daphne Hosinski. “Our patients are still going to get their doctor’s personal, high-quality care, but now we will have all the resources of Lexington Clinic to draw upon.”

Lexington Clinic was founded in 1920 and is Central Kentucky’s oldest and largest group practice. With 350+ providers in 30 different specialties, Lexington Clinic has more than 25 locations and serves about 600,000 patients yearly throughout Central Kentucky.

For more information about Lexington Clinic, please visit lexingtonclinic.com or follow them on Facebook (LexingtonClinicKY) and Instagram (lexclinky).

Patient Experience and Safety Awards Go to Frankfort Regional Medical Center

FRANKFORT Frankfort Regional Medical Center was recognized as a 2024 Patient Safety Excellence Award™ and Outstanding Patient Experience Award™ recipient by Healthgrades. The Healthgrades Patient Safety Excellence Award™ evaluates risk-adjusted complication and mortality rates for approximately 4,500 hospitals nationwide.

“Our dedication to providing award-winning patient care isn’t just a goal, it’s our unwavering commitment,” said John Ballard, PhD, CEO of Frankfort Regional Medical Center. “Every member of our team plays a crucial role in upholding these standards and ensuring the well-being of every patient whom we have the privilege to care for each day.”

Frankfort Regional also received the 2024 Outstanding Patient Experience Award based on feedback from its own patients. Survey questions focused on patients’ perceptions of their hospital care, including cleanliness, noise levels, medication explanations and staff responsiveness.

Frankfort Regional Medical Center is a 173bed, acute-care facility serving Frankfort and surrounding communities. The hospital has been designated an Accredited Chest Pain Center with Primary PCI, Level III Trauma Center, Primary Stroke Center, and Certified Total Joint Care Program. Frankfort Regional Medical Center is an affiliate of HCA Healthcare.

Your Source for Graphic Design since 2003

Nicola Jabbour, MD

KY Eating Disorder Council Holds Advocacy Day

Annual event raises awareness for statewide health condition that is largely ignored.

LOUISVILLE The Kentucky Eating Disorder Council (KEDC), established in 2020 when Governor Andy Beshear signed KRS 210.051, held its 4th Annual Advocacy Day at the Capitol Rotunda on February 28, 2024. This event was hosted by Andrea Krause, MD, chair of KEDC.

For 2024, the KEDC established the KEDC Champion Awards to recognize some of the providers and advocates working across Kentucky to address eating disorders. This year the Council recognized four Champions: Brittany Badal, MD, with Norton Healthcare, for her work in Treatment and Recovery;

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Dennis Wilson for Community Awareness for his work founding Aubrey’s Song Foundation for Eating Disorders; Kari Gerth, LCSW, with University of Kentucky Children’s Hospital, for her work in Prevention and Education; and Dr. Zubi Suleman in Advocacy and Legislation for increasing awareness in medical professionals and working on policy and resolution of eating disorders, which is now formally integrated into the KMA policy framework.

KEDC’s mission is to support evidence-based eating disorder education, awareness, and treatment initiatives through ongoing research, community engagement, and strategic partnerships. KEDC is focused on developing and implementing eating disorder awareness, education, and prevention programs; identifying strategies for improving access to adequate diagnosis and treatment services; assisting the Cabinet for Health and Family Services (CHFS) in identifying eating disorder research projects; reviewing data collection and collaborating on research projects; and making legislative recommendations as appropriate.

The KEDC’s Advocacy Day is the Wednesday of the last week of February during the National Eating Disorder Association’s Eating Disorder Awareness Week. All KEDC meetings and activities, including Advocacy Day, are open to anyone interested in supporting the mission and vision.

For more information visit dbhdid.ky.gov/dbh/kedc.aspx  or follow on Facebook at facebook.com/KYEDC.

Dr. Brittany Badal, MD

Dennis w ilson, community activist

Kari Gerth, LCsw

Lexington Medical Society Holds “The White Coat Investor” Program

LEXINGTON A packed house of medical students, residents, interns, spouses, and practicing physicians were treated to an entertaining and enlightening talk about personal and professional finances on March 21, 2024, at the annual White Coat Investor program, presented by the Lexington Medical Society and sponsored by The Pain Treatment Center of the Bluegrass, Ten Day Bourbon, and SVMIC.

James Dahle, MD, an emergency medicine doctor, is a self-taught financial advisor and author. He founded The White Coat Investor in 2011. He produces a blog, podcasts, newsletters, books, online and courses and speaks at CME conferences and on social media.

His lively talk touched on eight financial topics:

• How money works

• How financial planning is effective at crushing physician burnout

• Student loan management in 2024

• Protecting against financial catastrophes

• What Thoreau taught us about investing

• Your biggest tax break

• The four pillars of paying for your kid’s college

• Beware of your spouse

A Q&A session followed Dahle’s talk along with a few private conversations. The next Lexington Medical Society event is the annual LMS Foundation Golf Tournament on Wednesday, May 29, at The University Club in Lexington. More information on the Lexington Medical Society is at www. lexingtondoctors.org and 859.278.0569.

The audience was paying attention as Dr. James Dahle advised new doctors how to get rid of medical school debt: “Live like a resident.”

Lexington Medical Society president Angela Dearing, MD, introduces James Dahle, MD, to the large audience.

Kathryn Boroughs and Chloe Embry, both 1Y-UK, met with Dr. Dahle after his talk for personal advice.

PHOTOS BY GIL DUNN

LEXINGTON MEDICAL SOCIETY FOUNDATION

34th ANNUAL GOLF TOURNAMENT

WEDNESDAY, MAY 29

University Club of Kentucky

4850 Leestown Road, Lexington, KY

12:00p Registration/Lunch

1:10p Announcements

1:30p Start

SCRAMBLE format

Lunch & Awards Dinner

$200/player or $800/foursome

ALL PROCEEDS TO BENEFIT MEDICAL NON-PROFITS IN THE LEXINGTON AREA

Email cmadison@lexingtondoctors.org to register

Presented by

WHITE TEE SPONSORS

HOLE SPONSOR

LUNCH SPONSOR

TEAM SPONSORS

DONATIONS

toast

Broadway star and Lexington native Laura Bell Bundy sings Happy Birthday to the American Heart Association for its 100-year anniversary.

Central KY Heart Ball

Lights Up Downtown Lexington

LEXINGTON

The Central Kentucky Heart Ball was held on Friday, March 1, at the Central Bank Center in Lexington. The American Heart Association celebrated its 100th birthday at the event, which was led by chair couple Chris Roty, president of Baptist Health Lexington, and his wife, Lynn. As an added surprise, Keith Yarber, longtime board trustee and volunteer, announced the 100 Good Men initiative, which consisted of 115 men contributing $1,000 each to raise a total of $115,000, making it the largest individual Open Your Heart gift in the history of the Central Kentucky Heart Ball.

PHOTOS BY JOE OMIELAN

Lynn Roty gives opening remarks while husband Chris Roty, market president, Baptist Health, looks on.

Tony Houston, market president, CHI Saint Joseph Health, gives a

at the American Heart Association Gala.

Republic Bank area president Todd Ziegler, Joe Palumbo, and Kentucky State Representative Ruth Ann Palumbo.

Geri Tomassoni, MD, EP, Baptist Health Lexington, and John Cummins, DvM.

Malia and George Dimeling, MD, cardiothoracic surgeon, CHI Saint Joseph Health.

Scott Neal, CPA, CFP, and MD-Update financial columnist, with his wife Jennifer Burchett.

Andy Henderson, MD (ret), former Lexington Clinic CEO, and current chair of God’s Pantry, with wife Peggy.

Republic Bank’s table included Lawrence Wetherby, senior business banking officer, Emily Chambers, treasury management officer, Emily Miller, market manager, and Todd Ziegler, market president.

Hamid Mohammadzadeh, MD, cardiothoracic surgeon at CHI Saint Joseph Health, and wife Sepideh.

Sidney Johnson, nursing student at EKU, with her mother Kristy Salley, APRN, CHC at Baptist Health Lexington.

Sheila Griffeth, MSN, RN, market vP, CHI Saint Joseph Health, and husband Neil with Yousef Darrat, MD.

Lee Dossett, MD, CMO, Baptist Health Lexington, and wife Jennifer, RN.

Rebecca and Tony Houston, FACHE, market CEO, CHI Saint Joseph Health.

Olivia and Damir Kusmic, MD, CHI Saint Jospeh Health, with Clare and Hartej Dhillon, MD, Lexington Clinic ER.

Kentuckiana Heart Ball Hits Another Record

LOUISVILLE The Kentuckiana Heart Ball was held on Saturday, February 24, at the Omni Hotel in Louisville, under the leadership of chairman Rob Jay, CEO of ScionHealth. The event celebrated another record-breaking year, raising nearly $1.5 million in the battle against heart disease and stroke. During the event, the Live Fierce. Stand for All. Award, sponsored by ScionHealth and given annually to a person in Kentuckiana who has made an impact on advancing equitable health outcomes, was presented to Dr. Helen Collins, assistant professor at the University of Louisville in the Division of Environmental Medicine.

PHOTOS BY GIL DUNN

Mehak and Siddharth Pahwa, MD, with Deb Riley, vice-president, UofL Health Cardiovascular Services, and Chris Mike.

Alexandria and Eric Kreps, MD, cardiologist, Baptist Health.

Kevin Parrott, MD, cardiologist, Baptist Health, and wife Leslie.

Sebastian Pagni, MD, cardiothoracic surgeon, Baptist Health, and wife, Jenny.

Mary Marshman, DNP, RN, CNO, Jewish Hospital/UofL Health, and Shari Kretzschmer, RN, senior vice-president, patient services, and CNO, UofL Health.

Lung Cancer Screening is easy

Covered by most insurance (Medicare 50 - 77)

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Get screened every year to catch cancer early

Lung cancer can be treated if caught early!

“Kentucky has achieved notable success in a state with dismal lung cancer incidence, mortality, smoking rates and 5-year survival

We are now #2 in the country for lung cancer screening.”

Michael R. Gieske, MD Director of Lung Cancer Screening St Elizabeth Virtual Health Center

You are eligible for screening if:

50 You are 50 to 80 years old

20 15

You smoked a pack of cigarettes a day for 20 years

You currently smoke or quit within the past 15 years